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South African surgical first by UCT Private Academic Hospital and Groote Schuur

While brachytherapy has been used previously as a treatment for eye tumours, a collaboration between UCT Private Academic Hospital and Groote Schuur Hospital has now used it to treat a rare eye condition, according to a news release.

Hearing that your baby boy needs sight-saving surgery at the age of just nine months is difficult news for any parent to receive, especially when the condition is so rare that options are limited to a highly specialised procedure requiring a particular team of medical experts, in another province.

This was the experience of Erica Croxford, whose son Anthony – known as AJ to his family – was diagnosed with a rare skin condition, juvenile xanthogranuloma, which resulted in a growth inside his left eye.

According to Dr Hamzah Mustak, an ocular oncology and oculoplastics specialist practising at UCT Private Academic Hospital, the condition usually presents as a benign lump or bump on the skin and is not usually cause for concern. However, more than one lesion on the skin can also be accompanied by a lesion in the eye, which can be serious. In AJ’s case, it had resulted in a growth causing glaucoma, or severe pressure in the eye, that could lead to loss of sight or even loss of the eye itself.

“When AJ came to us in June this year, we immediately prepared for a highly specialised procedure using brachytherapy, most often used to treat certain types of cancer,” said Mustak. “It’s a form of internal radiation therapy, whereby the radiation is temporarily implanted or placed at the affected area. While the growth in AJ’s eye was not cancerous, it needed to be eradicated to prevent the eventual loss of his eye.”

While Dr Mustak does use brachytherapy as a form of treatment on tumours in the eye, this was the first time it had been used in South Africa as a treatment for a patient with this particular condition. The unique collaboration between UCT Private Academic Hospital and Groote Schuur Hospital affords the opportunity for this highly specialised care to be available at the facility.

A mother’s instinct
This was neither the beginning nor would it be the end of AJ’s long journey with this rare condition. She said she felt a strong mother’s instinct about a small mark she noticed shortly after her son’s birth. “When AJ was just two days old I saw this mark on his cheek and had a feeling there was something not quite right about it. The doctors I spoke to couldn’t tell me what it was but did not seem too concerned, so I tried to put it out of my mind,” she said.

“Then in December 2020 I noticed another mark on his armpit but little did we know that this was juvenile xanthogranuloma and that more than one skin lesion could indicate another in his eye. Shortly after that, around New Year, he woke up one morning with a terribly swollen, milky eye and no movement in the pupil. I took him straight to the doctor and that is when the journey really began. He was just four months old.”

The weeks and months that followed would be some of the most difficult that AJ and his family would have to endure. During this time AJ was referred to an ophthalmologist who, after taking a biopsy of the mark under AJ’s arm, was able to diagnose his condition.

By this stage the pressure in AJ’s eye had increased dramatically and he had to undergo several treatments as well as four operations to try to treat the glaucoma and the tumour in his eye. Despite all of these efforts the membrane of hiz eye had grown out of control, and he was referred to Mustak.

Specialised treatment at UCT Private Academic Hospital
“After seeing AJ in early June, it was clear we needed to try brachytherapy, which reduces the chances of unaffected tissues getting some radiation, as is the case with external beam radiation,” noted Mustak. “We are the only unit in South Africa offering customised brachytherapy for the eyes and we gad to custom-design the radiation implant for AJ, which was done in consultation with my colleague at the hospital, radiation oncologist Dr Julie Wetter.

"The process begins with examining the eye, taking measurements and then designing a template. A dosage is then calculated for the delivery of focused radiation to the tumour.

“From there the template and dosage calculations are provided to physics experts who, using complex mathematics, calculate and create the plans for the production of the implant, which in this case was made of stainless steel, with the precise radiation dosage embedded within.

“When it comes to brachytherapy in the eye, there is an additional layer of complexity to the process, as this is an organ that moves a lot. So we needed to use a particular design, like a big ring, to secure the implant so that when there is movement the implant remains anchored to the eye muscles."

The procedure on AJ took around 40 minutes, after which the implant remained inside his eye socket for 17 hours to allow the radiation to be delivered to the tumour, before being removed again.

“The success rate for brachytherapy in the eye is more than 90% so we hope the tumour will not grow back and that AJ regains vision in that eye again,” said Mustak.

Finding a way to make it happen
Such a complex procedure requires considerable resources, and before the procedure took place it became apparent affordability would be a challenge for the Croxfords, because UCT Private Academic Hospital is not part of the contracted hospital network of their medical scheme. This would result in the cost of the procedure not being covered fully and would therefore be virtually impossible for the family to afford.

“The fact was, there was no other solution for AJ to get the care he so desperately needed – this was the only option. I discussed this with hospital management and we found a way to ensure that AJ had a chance at having his eyesight saved,” said Mustak.

According to Lizl Rodrigues, hospital manager at UCT Private Academic Hospital, the facility and its staff were honoured to have played a role in providing little AJ with the opportunity to have his sight restored. “We are so privileged that this highly specialised form of treatment could be provided here at our hospital and we are glad that we could help to make it more accessible for this little patient and his family.”

Slightly more than three weeks have passed since AJ’s brachytherapy and, having taken him for two pressure check-ups back home in KwaZulu-Natal, his mom is happy to report his eye pressure has now stabilised at a healthy level. “It’s not yet the end of the road, as he will cataract surgery at some point in the near future.

“Only after that will we really know what his vision will be like in that little eye. However, the outlook is for now very positive, thanks to the incredible Dr Mustak, his colleagues and the amazing team at UCT Private Academic Hospital,” she said.


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